Enter your first and second choice of Dental Office Number (Search for Provider Number )

Existing Patient

1st Choice*

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Spouse Information

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Last

First Name

First

M.I.

SSN

Date of Birth

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Gender

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Female

PCD ID #

Enter your first and second choice of Dental Office Number (Search for Provider Number )

Existing Patient

1st Choice

Yes

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Dependent Information

Last Name

Last

First Name

First

M.I.

Relationship

SSN

Date of Birth

Insurance Status

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Gender

Male

Female

PCD ID #

Enter your first and second choice of Dental Office Number (Search for Provider Number )

Existing Patient

1st Choice

Yes

No

Dependent Information

Last Name

Last

First Name

First

M.I.

Relationship

SSN

Date of Birth

Insurance Status

Add

Cancel

Gender

Male

Female

PCD ID #

Enter your first and second choice of Dental Office Number (Search for Provider Number )

Existing Patient

1st Choice

Yes

No

Dependent Information

Last Name

Last

First Name

First

M.I.

Relationship

SSN

Date of Birth

Insurance Status

Add

Cancel

Gender

Male

Female

PCD ID #

Enter your first and second choice of Dental Office Number (Search for Provider Number )

Existing Patient

1st Choice

Yes

No

Dependent Information

Last Name

Last

First Name

First

M.I.

Relationship

SSN

Date of Birth

Insurance Status

Add

Cancel

Gender

Male

Female

PCD ID #

Enter your first and second choice of Dental Office Number (Search for Provider Number )

Existing Patient

1st Choice

Yes

No

Dependent Information

Last Name

Last

First Name

First

M.I.

Relationship

SSN

Date of Birth

Insurance Status

Add

Cancel

Gender

Male

Female

PCD ID #

Enter your first and second choice of Dental Office Number (Search for Provider Number )

Existing Patient

1st Choice

Yes

No

Dependent Information

Last Name

Last

First Name

First

M.I.

Relationship

SSN

Date of Birth

Insurance Status

Add

Cancel

Gender

Male

Female

PCD ID #

Enter your first and second choice of Dental Office Number (Search for Provider Number )

Existing Patient

1st Choice

Yes

No

Dependent Information

Last Name

Last

First Name

First

M.I.

Relationship

SSN

Date of Birth

Insurance Status

Add

Cancel

Gender

Male

Female

PCD ID #

Enter your first and second choice of Dental Office Number (Search for Provider Number )

Existing Patient

1st Choice

Yes

No

Broker Information

Broker Name or Agency Name*

First

I UNDERSTAND THAT

Premium notices will be emailed to the address entered above.

Coverage of the various programs may terminate for failure to pay any of the fees and dues required by AAQHC, An Administrator.

Any misrepresentation or omission in answering any part of any application may result in the cancellation of my membership, and I agree to pay for any and all services arising from the misrepresentation or omission.

As a member, I will receive the Membership Benefits package and may be eligible for optional programs available through AAQHC.

There is a one time enrollment fee of $10.00 payable with the application.

The monthly administration fee is $5.00, and the membership dues are $1.00 per month, beginning the second month of coverage.

All fees and dues are non-refundable.

The effective date for coverage is the first of the month only. Policies cannot be prorated for cancellations or enrollments.

The monthly payment for AAQHC membership and any optional benefits must be received in the office of AAQHC, An Administrator, by the 15th of the month preceding the benefit period. Failure to make the monthly payment may cause all AAQHC benefits to terminate and/or reinstatement charges to be assessed which are equal to a minimum of $5.00 or 5% of the premium amount due up to a maximum of $150.00. The member is responsible for payment even if premium statement is not received.

Returned checks will be assessed a $25.00 service charge and are subject to late charges.

I may subsequently terminate my membership with a thirty (30) days' prior written notice to AAQHC, An Administrator, and have no obligation except that which accrued during the time of my membership. If I terminate my membership entirely or if I terminate the dental benefits portion of my membership only, I acknowledge that I will not be eligible to re-apply to AAQHC, An Administrator, for dental benefits for one year from the date of termination.

All applications must be received in the office of AAQHC, An Administrator, by the 20th of the month preceding a benefit period (coverage month) in order to be considered for that benefit period. The effective date is always the first of the month following approval of application by the underwriter.

It is my responsibility to keep AAQHC, An Administrator, apprised of any change in status as it affects state or federal laws or regulations.

AAQHC, An Administrator, reserves the right to deny any application.

AAQHC, An Administrator, has the authority to execute all policies and agreements with providers chosen to provide benefits in accordance with any applicable federal and state law.

It is understood that AAQHC, An Administrator, and its related entities uses binding arbitration to settle all disputes with its members, including claims of medical malpractice and disputes relating to the delivery of service under the plan. It is understood that any dispute between AAQHC, An Administrator, and any of its members, including disputes as to medical malpractice, that is as to whether any medical services were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by constitutional right to have any dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. It is understood that this agreement to arbitrate shall apply and extend to any dispute for medical malpractice, relating to the delivery of service under the plan, and to any claims in tort, contract or otherwise, between AAQHC, An Administrator, and any individual(s) seeking services under the plan, whether referred to as a member, subscriber, dependent, enrollee or otherwise (whether a minor or an adult), or the heirs-at- law or personal representatives of any such individual(s), as the case may be.

*The undersigned applicant certifies that to the best of his/her knowledge and belief, all of the responses given are true, correct and complete. The applicant understands that a false statement or misrepresentation in the application may result in loss of coverage in the policy, the rescission of the policy or a revision of the rates quoted. It is further understood that no insurance will be effective until the plan is accepted in writing by AAQHC, An Administrator. No contract of insurance is to be implied in any way on the basis of completion and submission of the application."